Introduction
Intra-aortic balloon pump (IABP) is the commonest circulatory assist device that is used in critically ill patients with decreased cardiac output. This assists during diastolic phase of cardiac cycle.
Definition
The IABP is a mechanical device that provides temporary circulatory assistance to the compromised heart through controlled mechanical displacement of blood volume in the aorta.
Purposes
- To decrease afterload which will result in increased forward blood flow.
- To improve blood supply to the coronary arteries.
- To decrease myocardial oxygen demand and increase myocardial oxygen supply.
- To increase blood pressure.
- To decrease pulmonary artery pressure.
- To improve cardiac output and ejection fraction.
Indications
- Severe unstable angina that does not respond to pharmacological therapy.
- Heart failure-LV failure due to MI/cardiac surgery.
- Cardiogenic shock secondary to MI.
- Refractory unstable angina.
- Complications of acute MI [i.e., acute mitral regurgitation (MR) or ventricular septal defect (VSD), or papillary muscle rupture].
- Support for diagnostic, percutaneous revascularization, and interventional procedures.
- Ischemia-related intractable ventricular arrhythmias.
- Septic shock.
- Weaning from bypass.
- Hemodynamic instability among patients who wait for cardiac transplantation.
- Prophylactic support in preparation for cardiac surgery.
- Postsurgical myocardial dysfunction/low cardiac output syndrome.
- Myocardial contusion.
- Mechanical bridge to other assist devices.
Contraindications
- Severe aortic insufficiency.
- Abdominal or aortic aneurysm.
- Severe calcified aorta-iliac disease or PVD.
- Scarring of the groin, or other contraindications to percutaneous insertion.
- Irreversible brain damage.
- Bleeding disorders.
Articles
| Articles | Purpose |
| Cardiac monitor | To monitor ECG and vitals of the patient. |
| LABP kit (introducer and sheath), intra-aortic balloon and console | For IABP insertion. |
| Pressure monitoring kit (transducer, pressure cable, heparin saline, and pressure bag) | To measure arterial pressure. |
| Disposable electrodes | To connect the wires. |
| Spotlight | To aid in visualization. |
| Intravenous cut down set | For IABP insertion. |
| Towel pack, sterile gown bundle, sterile linen bundle | To create a sterile field and to perform the procedure aseptically. |
| Sterile gloves, mask, cap, and goggles | For personal protection and to prevent spread of microorganisms. |
| Lignocaine 2% (without adrenaline) | To anesthetize the surrounding skin. |
| 10-mL syringe (2 nos.) | To withdraw local anesthesia. |
| Insyte (18G/22G) | To start IV line. |
| Single lumen | For IABP insertion. |
| Sutures (1-0 silk/2-0 silk) | To fix the lumen in situ. |
| Povidone-iodine solution | To clean the skin. |
| Elastoplasts and scissors | To secure the line. |
| Crash cart | To intervene in case of emergency. |
Procedure
| Nursing Action | Rationale | |
| 1. | Explain the procedure to the patient and family. | Enhances cooperation. |
| 2. | Inform that the procedure will be performed in ICU or cardiac catheter lab. | Decreases anxiety. |
| 3. | Encourage family members to involve in patient’s care. | Promotes compliance. |
| 4. | Ask to verbalize fears. | Discussion helps to decrease fear. |
| 5. | Ensure that consent is obtained. | Avoids ethical and legal issues. |
| 6. | Ensure that coagulation results have been obtained prior to procedure. | Abnormal findings might contradict the procedure as bleeding may occur. |
| 7. | Ensure that the patient is connected to cardiac monitor and assess color, temperature, capillary refill, peripheral pulses, and sensation of both legs. | Obtains baseline vitals prior to procedure and aids for comparison of findings during and postprocedure. |
| 8. | Start IV line. | A patent IV line is necessary to administer sedatives and drugs during emergency. |
| 9. | Administer antianxiety medications as per order. | Reduces anxiety. |
| 10. | Determine patients’ coping mechanism. | Helps in identifying their level/type of coping and to act accordingly. |
| 11. | Ensure that pressure monitoring system is connected to the central lumen. | Invasive pressure monitoring is more reliable than noninvasive monitoring. |
| Insertion of IABP and preparation of IABP console | ||
| 12. | Plug in console power cord and switch it on. | Ensures working condition of the equipment. |
| 13. | Open helium tank and check for adequate supply. | Helium gas is utilized to inflate aortic balloon. |
| 14. | Connect the transducer to the console and perform zeroing. | Diastolic filling times of LV and aorta are inversely proportional to heart rate. Lesser balloon augmentation per unit time occurs due to shorter diastolic time. |
| 15. | Set time for inflation and deflation. | |
| Setting trigger and timing | ||
| 16. | IABP identifies the beginning of the cardiac cycle by trigger. | The inflation and deflation sequence is integrated with the events of cardiac cycle by the console. |
| 17. | ECG triggers use “R” wave to initiate the pumping. | Trigger gas delivery is synchronized with the patient’s ECG, this time, the duration of inflation and deflation in conjunction with the patient’s arterial pressure waveform. |
| 18. | The pressure trigger uses arterial waveform to pump. | For IABP to pump effectively, ECG signal is used to trigger the balloon and pressure signal for timing the counter pulsation. The frequency of initial IABP is set as 1:1. The subsequent changes will be made as per physician’s order. |
| During insertion | ||
| 19. | Assist during insertion of the IABP catheter. | |
| 20. | Ensure that chest X-ray is taken. | To confirm the presence of catheter. |
| 21. | Reassure the patient during procedure. | To alleviate anxiety. |
| 22. | Ensure and maintain strict asepsis throughout the procedure. | Prevents infection. |
| 23. | Monitor ECG; choose the lead with largest R wave without any artifact. | R wave of ECG is sensed by the console to trigger the gas delivery. |
| 24. | Initiate IABP counterpulsation promptly after insertion and adjust the duration of inflation and deflation based on the arterial waveform. | Patient’s cardiac cycle is integrated with the sequence of inflation and deflation of the balloon, this process is dependent on clear and continuous tracing of ECG. |
| 25. | Check the arterial pressure of the patient with and without balloon augmentation. | Assesses the effectiveness of the therapeutic procedure. Inflation should ideally begin at the dicrotic notch of the arterial waveform and deflation before the subsequent systole. |
| 26. | Evaluate the patient’s end diastolic pressure with balloon-assisted end-diastolic pressure. | Balloon-assisted end-diastolic pressure must be lower, which implies a decrease in afterload. |
| 27. | Check vital signs every 15-30 minutes for 4-8 hours, and then every hour, if stable, and neurological status every 2 hours. | For close monitoring and to intervene promptly if complications arise. |
| 28. | Maintain intake and output chart. | Provides baseline for fluid status. Decrease in urine output during posttherapy initiation may imply renal artery emboli. |
| 29. | Inform if chest pain occurs immediately. | To intervene promptly. |
| 30. | Look for bleeding from the IABP insertion site every hour for the first 8 hours and then every 4 hours. If present, apply direct pressure and report to physician. | Helps in recognizing early signs and symptoms of compartment syndrome. Applying direct pressure impedes blood flow. |
| 31. | Assess peripheral pulses for quality, character, and rhythm every 15 minutes for the first hour, then every 30 minutes, the second hour, and then every hour. | To assess the perfusion to the extremities. Ischemia of the lower extremity may occur due to occlusion of the femoral artery by the IABP catheter itself or emboli. |
| 32. | Monitor skin temperature, color, sensation, and movement of affected extremity. | To rule out ischemia (skin with bluish discoloration, cool, mottled,painful/numb/tingling sensation). |
| 33. | Auscultate bowel sounds. | Decreased or absent bowel sounds are suggestive of ischemia. |
| 34. | Check creatine kinase (CK) levels. | Increased CK level is suggestive of compartment syndrome. |
| 35. | Change position every 2 hours by logrolling technique. Keep foot end of bed elevated to 30°. | Prevents dislodgement of catheter. |
| 36. | Encourage passive range of exercises Q2h. | Promotes venous circulation. |
| 37. | Change the dressing at the insertion site Q24h. | To prevent infection. |
| 38. | Check IABP waveform at the beginning of each shift and Q1h. The wave form should consist of 2:1 tracings. One is assisted and other is unassisted waveform. | This is appropriate when lead gets disconnected or trigger is lost. |
| 39. | Switch on the monitor alarm; set augmentation 10-15 mmHg below optimal pressure. | |
| 40. | Do not withdraw blood from IABP port. Flush the system when IABP is in standby mode. Do not flush when balloon is inflating or deflating. | Air emboli may occur. |
| 41. | Administer anticoagulants as per order and check coagulation levels Q8h to Q12h. | To identify and treat bleeding at the earliest. |
| Weaning | ||
| 42. | Counterpulsation can be reduced from 1:1 to 1:2 and finally 1:3 depending on the patient’s hemodynamic parameters. | 1:1 represents one IABP cycle of inflation and deflation for every heartbeat. |
| 43. | Observe for indicators which will allow to wean the patient from IABP, such as decreased angina; HR: <110/min; MAP: > 70 mmHg without vasopressor, PAWP: <18 mmHg; cardiac index: >2.4; capillary refill: <2 seconds; SVO₂: 60-80%; urine output: >0.5 mL/kg/h. | To wean the patient from IABP. |
| Documentation | ||
| 44. | Document the following: Date, time of insertion, and patient’s response to the procedure.Hourly IABP ratio and augmentation level.Pre-ECG findings.Catheter insertion site.Augmentation.Settings.Vital signs. | For continuity of care. |
Special Considerations
- Ensure helium tank is full and tubing connections are secure.
- Zero the transducer and calibrate arterial pressure monitoring.
- ECG & arterial pressure waveforms should be continuously observed.
- Hourly checks of MAP, diastolic augmentation, and balloon pressure.
- Assess pedal and radial pulses to detect limb ischemia.
- Avoid prolonged standby mode (>30 minutes) to prevent clot formation.
- Monitor for signs of balloon migration (e.g., absent pulses, reduced urine output).
- Check for blood in tubing, which may indicate balloon rupture.
- Gradual frequency reduction (1:1 → 1:2 → 1:4) before removal.
- Assess hemodynamic stability before discontinuation.
- Post-removal monitoring for bleeding or limb ischemia.
REFERENCES
- Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
- Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
- Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwers, ISBN-13:978-9388313285
- Adrianne Dill Linton, Medical-Surgical Nursing, 8th Edition, 2023, Elsevier Publications, ISBN: 978-0323826716
- Donna Ignatavicius, Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care, 11th Edition ,2024, Elsevier Publications, ISBN: 978-0323878265
- Lewis’s Medical-Surgical Nursing, 12th Edition,2024, Elsevier Publications, ISBN: 978-0323789615
- AACN Essentials of Critical Care Nursing, 5th Ed. Sarah. Delgado, 2023, Published by American Association of Critical-Care Nurses ISBN: 978-1264269884
- Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2024. PART IV, NURSING PROCESS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK610818/
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